HIV Dermatology

1. HIV Dermatology Medical Student Core Curriculum In Dermatology Updated September 6, 2011

2. Module Instructions • The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology. • We encourage the learner to read all the hyperlinked information.

3. Goals and Objectives • The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of HIV-positive patients presenting with skin disease. • By completing this module, the learner will be able to: • Identify and describe the morphology of the dermatologic conditions presented in this module • Discuss the relationship between the level of immune suppression and the skin diseases seen in HIV positive individuals • Discuss the importance of highly active antiretroviral therapy in the treatment of skin conditions in patients living with HIV/AIDS

4. Introduction to HIV Dermatology • 80-90% of patients with HIV have dermatologic disease • HIV-infected individuals have a defect in cell-mediated immunity which predisposes them to certain infections (bacterial, fungal, mycobacterial, viral), many of which have skin findings • HIV-positive patients are also at increased risk for neoplasms, inflammatory dermatoses, and drug reactions • Dermatologic disease common to the general population (e.g., seborrheic dermatitis) often has an increased prevalence or severity in HIV-positive individuals

5. HIV Dermatology (cont.) • Skin lesions may be the first sign of HIV infection • Ask abut risk factors for HIV infection when a patient < 50 yrs-old presents with herpes zoster (shingles) • Suspicion for HIV infection should be raised when a patient presents with multiple skin diseases (e.g., severe seborrheic dermatitis and thrush) • Some skin diseases are so characteristic of the immunosuppression of HIV-infection that their presence warrants HIV testing • Oral hairy leukoplakia, bacillary angiomatosis, and Kaposi sarcoma • Typically, antiretroviral therapy improves skin conditions that result from immunodeficiency

6. Skin Disease and CD4 Counts • Various skin manifestations of HIV infection can be correlated with levels of immune suppression • Skin disease associated with any CD4 Cell Count: • Herpes simplex virus • Varicella zoster virus • Staphylococcus aureus • Syphilis • More commonly associated with CD4 counts < 500 • Human papillomavirus • Scabies • Drug Reactions • Lymphoma

7. Skin Disease and CD4 Counts • More commonly associated with CD4 counts < 200 • Infection: Epstein-Barr virus (oral hairy leukoplakia), Candida, Bacillary angiomatosis , Molluscum contagiosum, Histoplasmosis, Coccidiomycosis • Inflammatory: Psoriasis, Seborrheic dermatitis, Acquired icthyosis, Atopic dermatitis, Xerosis • Neoplasm: Kaposi sarcoma • Other: Eosinophilic folliculitis • More commonly associated with CD4 counts < 50 • Cryptococcosis • Pruritic papular eruption (insect bite hypersensitivity)

8. Case One Mr. Edward Mitchel

9. Case One: History • HPI: Mr. Mitchel is a 53-year-old man who presents to dermatology clinic with a new rash on his chest, elbows, and knees. Rash does not itch or burn, but does cause him some emotional stress. • PMH: no major illnesses or hospitalizations • Medications: none • Allergies: none • Family history: mother with psoriasis • Social history: currently staying with a friend until he can find more stable housing • Health-related behaviors: no tobacco or alcohol use. Daily IV drug use x 5 years.

10. Case One: Skin Exam • Multiple well-circumscribed erythematous plaques with overlying scale on the trunk and extremities (not shown)

11. Case One, Question 1 • What is your next step(s) in evaluating this patient? • Admit him to the hospital • Look inside his mouth • Order a chemistry panel • Order an HIV test

12. Case One, Question 1 Answer: b & d • What is your next step(s) in evaluating this patient? • Admit him to the hospital (not necessary) • Look inside his mouth (inspection of the oral mucosa is part of the total body skin exam) • Order a chemistry panel (not necessary) • Order an HIV test (intravenous drug use is a risk factor for HIV)

13. Diagnosis: Psoriasis & Thrush • Many HIV-related mucocutaneous changes occur in the mouth • Upon further exam, Mr. Mitchel had evidence of oral candidiasis • Mr. Mitchel was diagnosed with plaque psoriasis and thrush • The results of his HIV test came back positive • He was provided with resources and counseling for his diagnosis of HIV

14. HIV and Psoriasis • Psoriasis is a common disease in the general population and in patients with HIV • When patients have pre-existing psoriasis, the severity of their psoriasis may worsen in the course of their HIV infection • Psoriatic arthritis is more common and severe in HIV-positive individuals Refer to the module on Psoriasis for more information

15. HIV and Psoriasis Similar to the general population, HIV-positive individuals with psoriasis can have multiple coexisting patterns at the same time or over time Plaque Psoriasis Inverse Psoriasis* Pustular psoriasis Erythrodermic psoriasis* Guttate psoriasis+ * More commonly seen in HIV-positive individuals + Test for syphilis when HIV-positive patients present with guttate lesions because the lesions of syphilis may mimic guttate psoriasis

16. Treatment for Psoriasis in HIV • Similar to all patients with psoriasis, the general approach to treating HIV-associated psoriasis is to tailor therapy according to the patient’s disease severity and preference: • Mild to moderate disease: topical treatment (steroids, retinoids, vitamin D analogs) • Moderate to severe disease: phototherapy, oral retinoids, or both may be used as second-line treatment • Refractory, severe disease: refer to a HIV specialist and dermatologist for consideration for immunotherapy

17. Treatment for Psoriasis in HIV • The institution of HAART therapy in HIV-positive patients with psoriasis will improve their skin disease • Many effective medications for psoriasis and psoriatic arthritis are immunosuppressive and can lead to severe complications use cautiously and monitor for side effects • Low threshold to refer a patient with HIV and co-existing psoriasis to an HIV specialist and dermatologist

18. Case Two Mr. Donald Conrad

19. Case Two: History • HPI: Mr. Conrad is a 38-year-old, HIV-positive man (unknown last CD4 count, not on HAART) who presents with “bumps” behind his ear as well as well as white spots on his tongue and mouth • PMH: HIV diagnosed 5 years ago, no hospitalizations • Medications: none • Allergies: none • Family history: no history of major illnesses or cancers • Social history: lives downtown with his girlfriend • Health-related behaviors: no tobacco, alcohol, or drug use • ROS: new odynophagia

20. Case Two: Skin Exam • Multiple discrete, dome-shaped, solid, skin-colored papules with central umbilication. • Some appear smooth while others appear verrucous.

21. Case Two: Skin Exam • Multiple white papules on the palate and posterior pharynx coalescing into plaques • Removal with dry gauze pads leaves an erythematous mucosal surface

22. Case Two, Question 1 • What is the patient’s likely diagnosis(es)? • Basal cell carcinoma • Molluscum contagiosum • Oral candidiasis • Verruca vulgaris

23. Case Two, Question 1 Answer: b & c • What is the patient’s likely diagnosis(es)? • Basal cell carcinoma • Molluscum contagiosum • Oral candidiasis • Verruca vulgaris

24. Molluscum Contagiosum and HIV • Molluscum contagiosum (MC) is a benign, usually asymptomatic viral infection of the skin • Caused by a DNA poxvirus • Spread through direct skin to skin and sexual contact • Lesions are commonly found on the face and genitals • Usually presents as firm, skin-colored, dome-shaped papules with central umbilication • In HIV-positive patients, lesions may be more numerous, more verrucous, larger and much less likely to spontaneously resolve

25. MC Evaluation and Treatment • Diagnosis is often made clinically • Diagnosis can also be made by extracting the contents of the lesion and examining microscopically after staining • May also use a skin biopsy if diagnosis is unclear • The institution of HAART therapy in HIV-positive patients frequently leads to the resolution of molluscum, so adequate treatment of HIV disease should first be verified and monitored Refer to the module on Molluscum Contagiosum for more information regarding treatment

26. Oral Candidiasis • Candida is a normal inhabitant of the human oropharynx and GI tract • Oral candidiasis (thrush) is the most common fungal disease of HIV-positive patients • Lesions most characteristically appear as white plaques on the tongue or buccal mucosa that can be scraped off with a tongue blade (or dry gauze), producing bleeding or red macular atrophic patches

27. Oral Candidiasis • HIV-infected patients can have all of the following patterns of oral candidiasis: • Pseudomembranous (thrush): as described above • Erythematous (atrophic): smooth, red atrophic patches • Hyperplastic (leukoplakia): white plaques that cannot be wiped off but regress with prolonged anticandidal therapy • Angular cheilitis: erythema and erosion at the corners of the mouth

28. Candidal Infection and HIV • Oropharyngeal candidiasis may coexist with candidal esophagitis, which is the most common cause of odynophagia and dysphagia in HIV-infected patients • Patients may also exhibit chronic and refractory vaginal candidiasis, paronychia and onychodystrophy, and candidal intertrigo • Culture or microscopic visualization of pseudohyphae and yeast forms can be used to confirm the diagnosis of mucocutaneous candidiasis

29. Case Two, Question 1 • Which of the following is the best treatment option for Mr. Conrad? • Clotrimazole troches • Nystatin suspension • Oral cephalexin • Oral fluconazole

30. Case Two, Question 1 Answer: d Which of the following is the best treatment option for Mr. Conrad? Clotrimazole troches (used to treat oropharyngeal candidiasis) Nystatin suspension (used to treat oropharyngeal candidiasis) Oral cephalexin (a cephalosporin antibiotic will not help treat candidiasis) Oral fluconazole (patient likely has oropharyngeal + esophageal candidiasis, which requires systemic treatment)

31. Mucocutaneous Candidiasis Treatment • Oral candidiasis generally responds to local application of nystatin or clotrimazole • However, some patients may require oral medications or intravenous medications • Systemic agents are recommended for the treatment of esophageal candidiasis • If no improvement within 72 hours, endoscopy may be necessary • The presence of oral candidiasis in a patient without known risk factors for thrush should raise suspicion for HIV infection • Risk factors include the use of steroids inhalers, oral antibiotics, systemic steroids, and other forms of immunosuppression

32. Case Three Mr. Daniel Lawson

33. Case Three: History • HPI: Mr. Lawson is a 55-year-old man who was admitted to the hospital for altered mental status and rash with numerous crusted lesions all over his body, with minimal pruritus. 2/2 blood cultures drawn in the emergency room were positive for S. aureus. • PMH: Diagnosed with HIV 9 years ago, last CD4 count of 36 checked 2 months ago. Dementia x 2 years (thought to be HIV-related).

34. Case Three: History • Medications: none, stopped HAART last year with plans to restart them now that he his living with his brother • Allergies: none • Family history: noncontributory • Social history: lives with his brother who has been itching but has not noticed any lesions • Health-related behaviors: reports a healthy diet, no tobacco, alcohol or drug use

35. Case Three: Skin Exam • Large hyperkeratotic plaques with deep fissures most severe on his buttock and feet. Scale is poorly adherent and falls off in large pieces.

36. Case Three, Question 1 • What is the most likely diagnosis? • Atopic dermatitis (widespread) • Crusted scabies • Herpes simplex (disseminated) • Psoriasis

37. Case Three, Question 1 Answer: b • What is the most likely diagnosis? • Atopic dermatitis (widespread) • Crusted scabies • Herpes simplex (disseminated) • Psoriasis

38. Scabies and HIV • Scabies is an infestation of the skin that results in an eruption of pruritic papules and burrows from the mite sarcoptes scabiei • Immune suppressed or neurologically impaired individuals are at increased risk of developing crusted scabies (hyperkeratotic scabies, formerly called Norwegian scabies) • Presents with thick, scaling, white-gray plaques with minimal pruritus that are often localized to the scalp, face, back, buttocks, and feet • Immunocompetent contact of persons with crusted scabies develop typical scabies • Fissures provide an entry for bacteria leading to increase risk for sepsis and death

39. Scabies Evaluation and Treatment • Microscopic examination of the scale reveals numerous mites, eggs, or feces • In non-crusted scabies, treat the infected individual and contacts with topical 5% permethrin cream • Crusted scabies is far more difficult to treat as there is an incredibly large number of mites • Patients should be monitored for secondary bacterial infection as it can result in fatal sepsis See the module on Infestations and Bites for more information

40. Treatment of Crusted Scabies • Typically combination therapy is used in in crusted scabies • Multiple doses of oral Ivermectin 200mcg/kg/dose depending on severity of infection • Topical permethrin 5% (or benzoyl benzoate 25%) 1-2x weekly, frequently more than two treatments is required • Given the high mite burden, patients with crusted scabies should be isolated and strict barrier nursing procedures instituted to avoid outbreaks in health-care facilities

41. Case Four Mr. Steve Rios

42. Case Four: History • HPI: Mr. Rios is a 48-year-old man who presents to his primary care provider with purple spots on his body. They do not cause him pain or pruritus • PMH: HIV+ for 12 years, last CD4 count 164 • Medications: none (stopped taking HIV medications 6 months ago) • Allergies: none • Family history: noncontributory • Social history: lives with two roommates in a house, works as a server at a restaurant • Health-related behaviors: no alcohol, tobacco or drug use • ROS: overall tired, depression without suicidal ideation

43. Case Four: Skin Exam • Scattered purple macules, plaques, and nodules of varying sizes and shapes, mainly found on the truck and face

44. Case Four, Question 1 • What is the most likely diagnosis? • Angiosarcoma • Bacillary angiomatosis • Kaposi sarcoma • Urticaria

45. Case Four, Question 1 Answer: c • What is the most likely diagnosis? • Angiosarcoma (angiosarcoma of the skin presents as singular or multifocal "bruise"-like patches on the skin, most frequently on the head and neck) • Bacillary angiomatosis (skin lesions appear as small red papules that may enlarge to become nodules) • Kaposi sarcoma • Urticaria(pruritic, elevated papules and plaques, often with erythematous, sharply-defined borders and pale centers)

46. Kaposi Sarcoma (KS) • Kaposi sarcoma is a vascular neoplastic condition linked to the infection with human herpesvirus 8 (HHV-8) • There are four different types of KS: • Classic: primarily affects men of Mediterranean and Jewish origin • Endemic: several types described in sub-Saharan Africa before the AIDS epidemic, typically not associated with immune deficiency • Epidemic: AIDS-associated type, is characterized by more aggressive and widespread mucocutaneous lesions • Iatrogenic: associated with immunosuppressive drug therapy, typically seen in solid transplant patients • May present as red or brown-violaceous macules, patches, plaques or nodules

47. Kaposi Sarcoma • The skin is most commonly affected, but mucous membranes, gastrointestinal tract, lymph nodes, and lungs may all be involved • Oral lesions are classically found on the hard palate • Remember to look inside the patient’s mouth • Cutaneous lesions occur most commonly on the trunk, the extremities, and the face (as opposed to classic KS, which mainly affects the feet and legs) • Diagnosis is confirmed with a skin biopsy (taken from the center of a firm lesion) • Depending on the patients symptoms, other diagnostic procedures such as chest radiograph or stool occult blood test may be needed to assess for associated internal lesions

48. Kaposi Sarcoma: Treatment • Every patient with HIV should be evaluated for treatment with HAART • Use of HAART has led to a marked decline in the prevalence of AIDS-related KS • Patients receiving HAART present with less aggressive KS and have significantly decreased morbidity and mortality • Referral to a dermatologist, HIV specialist, or oncologist is frequently required in managing KS in the setting of HIV

49. Kaposi Sarcoma: Treatment • Treatment will vary depending on extent of KS, immune status and associated systemic illnesses • Local treatment options include cryotherapy, radiation therapy, intralesional chemotherapy, or topical retinoid • Systemic chemotherapy is used for symptomatic systemic disease and widespread or rapidly progressive cutaneous involvement

50. HIV and Skin Cancer • Fair skinned, HIV-positive individuals commonly develop basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) of the skin • BCC is substantially more common than SCC in HIV-infected individuals, in contrast to organ transplant recipients, in whom SCC is more frequent • HIV-infected individuals are also more prone to developing HPV-associated genital insitu and invasive SCCs (rectal, cervical, penile cancer) • Melanoma in the setting of HIV disease tends to be more aggressive